Despite advances in hospital electrocardiographic (ECG) monitoring technology, monitoring practices are inconsistent and often inadequate. We recently published new practice standards for ECG monitoring. The primary purpose of our proposed 5-year multisite randomized clinical trial, which is guided by the knowledge transfer framework, is to test the effect of implementing these standards on nurses' knowledge and skills, quality of care, and patient outcomes. We will also explore the sustainability of effects in the experimental group and the effect of the delayed intervention in the control group. We expect that increased knowledge and skills of nurses will lead to enhanced quality of care, which will result in improved outcomes for patients. Units serving cardiac patients in 16 hospitals will participate. Hospitals will be randomized to the experimental or control group after baseline measures of knowledge and skills, quality of care, and patient outcomes are obtained. The intervention will include ECG monitoring education and strategies to implement and sustain change. The education will be Web-based and include 4 modules: essentials of ECG monitoring, arrhythmia monitoring, ischemia monitoring, and QT interval monitoring. The standardization of content, flexibility of use, immediate feedback in both practice and testing sections are advantages of Web-based education. The use of simulations to test skills makes our program innovative. The strategies to implement and sustain change in the clinical area include reinforcement of education, incentives, and the designation of champions on each unit who will actively promote the implementation of the practice standards. Statistical analyses will account for intra-cluster correlation at the hospital level. Most outcomes are categorical with 2 levels, whereas knowledge and skill scores are continuous. For categorical outcomes, two approaches will be considered: logistic regression models complemented with intra-cluster correlation using generalized estimating equations methods and extended Mantel-Haenszel cross-tabulation methods stratifying by cluster. For continuous outcomes, mixed modeling will be used to account for intra-cluster correlation through hierarchical linear models. We developed the new practice standards to improve hospital ECG monitoring. We expect that improved ECG monitoring will result in more accurate diagnosis and more timely treatment, which will lead to better outcomes for patients. PUBLIC HEALTH RELEVANCE: The purpose of this study is to test the effect of implementing new practice standards for electrocardiographic (ECG) monitoring on nurses knowledge and skills, quality of care, and patient outcomes. If implementation of the practice standards is associated with improvement in quality of care and patient outcomes, then there is the potential for improved care and outcomes for the literally millions of patients who require continuous ECG monitoring while hospitalized.